CVD Control Programs: Preventive Strategies

1
CVD Control Programs Preventive Strategies

• Sunita Dodani
• Department of Epidemiology
• University of Pittsburgh

2
Presentation overview

• Burden Of CVDs And Health Expenditures in
  developing countries
• Constraints For CVD Prevention In Developing
  Countries
• Barriers to Implementation of Preventive Services
• Prevention Strategies
• CVD Control Programs
• Population based high risk approach

3

• CVD identified as the primary NCD throughout the
  developing world and inflicting major economic
  and human costs.
• One of the main reasons are the epidemiologic
  transition.
• The observed ethnic diversity in the CVD and risk
  factors profile in South Asian Immigrant studies
  makes this population high-risk.
• A paucity of cause-specific mortality data and
  epidemiologic studies is a major impediment to
  the estimation of the absolute and relative death
  toll of CVD.
• Need to establish appropriate research studies,
  increase research capacity and preventive
  cardiology programs.

4
Potential For Prevention

• CVD risk factors large potential for prevention

Nonmodifiable RF Age, Sex, FM history of CVD

• Physiological RF
• Hypertension
• Cholesterol
• Diabetes
• Obesity

Endpoints Heart Disease Stroke Vascular
Disease Cancer
Behavioral RF Smoking, Unhealthy diet Sedentary
Lifestyles
Socioeconomic cultural determinants
Early life Characteristics
Modifiable
5
Burden Of Disease And Health Expenditures
Of Industrialized And Developing
Countries The 90/10 Disequilibrium
EME established market economy
6
Burden Of CVDs And Health Expenditures

• The mismatch between healthcare needs and
  resources is widened.
• An expanded list of health conditions calls for
  policy makers attention and public health
  action.
• Policy has to prioritize on the basis of disease
  burdens, cost-effectiveness and equity.
• The rising burdens of CVD exemplify the high
  costs and the adverse effects on development that
  would result from mid-life death and disability.

7
Constraints For CVD Prevention In Developing
Countries

• Limited recognition and available data on CVD
• Lack of commitment
• Prevention not taken seriously (market
  pressure favoring therapy)
• Stroke/ CHD considered as diseases for
  specialists to treat
• Health care needs not addressed
  prospectively by existing health system
• Costs are rising and resources are dwindling

8
Barriers To Achieving CVD Reduction

• Agencies Involved in Prevention
• Government
• very bureaucratic
• slow and ineffective
• failure to influence polices
• Cardiac societies and foundations
• effectiveness in reaching out to the public
  through the media
• Community and societal barriers
• strong health beliefs and lack of awareness,
  education and knowledge

9
Barriers to Achieving CVD Reduction

• Medical Education System
• Focused towards secondary tertiary care than
  Public health and prevention
• In- adequate training of medical professionals in
  research methods
• Communication skills knowledge deficit in most
  providers
• Providers attitudes about prevention

10
Barriers to Implementation of Preventive Services

• Community/Society/ patients
• Lack of motivation
• Cultural factors
• Social factors
• Lack of knowledge

• Health Care Systems
• Acute care priority
• Lack of resources
• Lack of systems for preventive services
• Time and economic restraints
• Lack of policies and standards

11
Barriers to Implementation of Preventive Services

• Physician Level
• Problem-based focus
• Little positive feedback
• Time
• Lack of training
• Poor knowledge
• Lack of skills
• Perceived low efficacy
• Lack of specialist-generalist
  communication

12
Preventive Cardiology Programs How Can We Do
Better?

• Development of strategies for the prevention of
  cardiovascular disease (CVD) presents an
  important policy question for society
• Do the benefits of these programs justify the
  investment?
• Substantial costs affordable ?
• How limited health care resources should be
  allocated to these activities?
• Will it cover the majority who are at risk?
• Who will benefit the most?
• What are the best approaches ?

13
CVD Control Programs

• The essential components of any CVD control
  program would be
• Establishment of efficient systems for estimation
  of CVD-related burden and its secular trends.
• Estimation of the levels of established CVD risk
  factors in representative population samples to
  help identify risk factors that require immediate
  intervention.
• Evaluation of emerging risk factors
• Development of a health policy that will
  integrate population-based measures for CVD risk
  modification and cost-effective case management
  strategies for high risk group.

14
Prevention Strategies

• Strategic Goals
• 1. Build a nationwide Cardiovascular Disease
  Prevention and Control Program
• 2. Eliminate health disparities among priority
  populations
• 3. Create a national surveillance system for CVD
  
• 4.Develop research capacity and skills by
  training the trainers
• 5.Support applied research

15
Prevention Strategies

• Three types of prevention are advocated by WHO
• Primordial prevention of appearance of risk
  factors
• e.g In the case of CAD and hypertension
• Primary control of risk factors of CVD
• e.g. Hypertension, smoking etc
• Secondary control of CVD to control
  complications and further deterioration
• e.g. RHD, MI or Angina

16
CVD Control Programs

• All of these require a strengthening of
  policy-relevant research that can support and
  evaluate CVD control programs in the developing
  countries.
• The challenge of CVD control is complex in
  settings in which epidemiological data CVD events
  as well as population-attributable risk CVD risk
  factors are not readily or reliably available at
  present.
• Research training and Pubic health knowledge are
  an important tool for CVD control in developing
  countries

17
Research training in Pakistan

• There are more than 50 medical universities and
  colleges
• Only 2 institutes have accredited public health/
  research training programs
• There is no school of public health
• Those trained, majority leaves
• Few publications in international journals
• Three journal are indexed

18
CVD Control Programs

• Research Priorities
• Public health action for CVD control linked to a
  policy-relevant research
• The classic sequence of long-term cohort studies
  followed by intervention trials to initially
  identify and later modify risk factors will be
  time consuming and is likely to be impeded by
  financial constraints.
• Public health action cannot afford to wait that
  long to initiate interventions.

19
CVD Control Programs

• The appropriate strategy would be to
• Commence control strategies, based on what we can
  readily extrapolate from the knowledge available
  from other populations.
• Evaluate known and putative risk factors through
  cross-sectional studies of populations
  (ecological comparisons) and case-control
  studies, preferably using incident cases of CVD
• Use of South Asian Immigrant study data as a
  surrogate to develop preventive programs

20
From Epidemiological Evidence to Prevention
Program

• Two complementary strategies that are
  advocated for primary prevention are Population
  based and High risk strategies approach
• Population based approach
• community wide interventions
• modify behavior
• influence the distribution of risk factors in a
  population
• modest changes in risk factors --substantial
  reduction in the cumulative population risk of
  CVD in a community
• small benefits to each individual

21
Strategies to prevent CVDs

• High risk approach
• identify few who are at high risk
• targeted behavioral or pharmacological
  interventions
• greatest risk reduction in individuals

22
Population and high risk preventive strategies
Population approach
Distribution Destiny
Risk factors
Original distribution
Combined Strategies
High risk approach
Risk Factor
23
Strategies to prevent CVDs
Primary Prevention (Limit the number of cases)

• High risk Strategies
• Clinical management
• Targets individual

• Population Strategies
• Public health approach
• Targets Population

24
Strategies To Prevent CVDs

• Population based approach How to do it?
• Culturally and linguistically appropriate and
  effective community health promotion and disease
  prevention programmes should be encouraged and
  made available.
• If they already exist they should be strengthened
  and integrated with the formal health care
  sector.
• Cardiovascular disease prevention should be
  integrated with primary heath care.
• Cardiovascular health education should be
  integrated with other health promotion
  initiatives.

25
Strategies To Prevent CVDs

• Population based approach
• Target population-wide lifestyle interventions,
• Population-wide screening for risk factors
• Lifestyle advice should center on tobacco
  cessation, weight control, a heart healthy diet,
  physical activity and stress management. e.g.
  Smart Heart Program
• Cardiovascular health promotion should be part of
  the national media strategy. e.g. National Action
  Program
• Cardiovascular health should be addressed in
  schools as part of the curriculum, e.g. Smart
  Heart Program
• Cardiovascular health education should be offered
  in places of religious worship and worksites
  where appropriate.

26
Strategies To Prevent CVDs

• Population based approach
• Infrastructure support and local capacity
  building for research should be prioritized.
• Train the trainers" approach should be adopted
  for promoting CVD prevention at the professional
  level.
• Community empowerment through education (mass and
  targeted) and policy change (to provide an
  enabling environment) are essential for health
  promotion.

27
Strategies To Prevent CVDs

• Some famous population based programs
• North Karelia Project. Puska P 1975
• Non-communicable disease intervention programme
  in Mauritius. Dowsen GK Br. Med J. 1995 311
  12559
• Five standford city project.
• Winkleby Am J Public Health 86 (1996), pp.
  17731779.

28
Strategies To Prevent CVDs

• High risk approach
• Identification of High Risk population from a
  community ( those with CVD, two risk factors of
  CHD, diabetics)
• Cost-effective and customized diagnostic and
  management algorithms should be developed for the
  treatment
• These guidelines should be made widely available
  to and adopted by health professionals in primary
  and secondary care settings.
• The availability of effective and affordable
  drugs, devices and procedures should be ensured.
• Referral chains should be established to provide
  effective links between primary, secondary and
  tertiary health care centers whenever required.

29
Strategies To Prevent CVDs

• High risk approach
• Physicians in South Asia usually lack support of
  related health professionals such as dietitians
  as is the norm in the developed world.
• A customized risk management curriculum should be
  introduced for physicians and health
  professionals during the course of formal and
  informal training.
• Specialist opinion should be sought whenever
  essential and feasible. The cut-off points for
  specialist referral for every risk category
  should be recognized.

30
Public Health Approach Vs. High Risk Strategy

• High-Risk
• Benefit for individual large
• Easy to understand, hence
• motivation and rewards for
• individuals
• Needs persons co-operation
• Limitations
• Impact on total burden small
• Often misused
• Costly (screening)
• Palliative (does not solve
  overall problem, rescue)
• Distracts from population
• approaches

• Population- based
• Radical ( incidence)
• Potential large benefits
• Cost effective (Policy)
• Can target unaware Population
• Limitations
• Need for mass change is hard to
• communicate
• Interventions other than policies
• hard to implement
• Benefit for individual small, weak
  motivation of physicians
• Intervention can challenge vested
• interests/societal norms

31
Strengthening Research Capacity

• Build Capacity Skills To Conduct Research
  Activities
• Standardized morbidity data to estimate CVD
  burden.
• Prevalence data from valid cross-sectional sample
  surveys of selected communities
• Incidence data from selected cohort studies would
  provide a reasonable basis for extrapolation.
• Develop disease surveillance system
• Develop CVD registries and data centers

32
Strengthening Research Capacity

• How much research training required for Health
  care professional to obtain basic research
  skills.
• Basic knowledge of Epidemiology, Biostatistics
  and Public health should be core components of
  post-graduate education and CME training programs
  for doctors.

33
Five Essential Components Of The Action Plan

• Taking Action
• Putting present knowledge to work
• Strengthening Capacity
• Transforming the organization and structure of
  public health agencies and partnerships
• Evaluating Impact
• Monitoring the Disease Burden, measuring
  progress, and communicating urgency
• CDC model, 2003

34
Five Essential Components Of The Action Plan

• Advancing Policy
• Defining the issues and finding the needed
  solutions
• Engaging in (regional and global) partnerships
• Multiplying resources and capitalizing on shared
  experience

35
Action Framework For A Comprehensive Public
Health StrategyTo Prevent Heart Disease And
Stroke
PREVENTION
36
Action Framework For A Comprehensive Public
Health StrategyTo Prevent Heart Disease And
Stroke
TREATMENT
37
(No Transcript)